Provider Demographics
NPI:1043334766
Name:BLACKMON, STACY L (DDS)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:L
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 VILLAGE HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710
Mailing Address - Country:US
Mailing Address - Phone:803-831-8856
Mailing Address - Fax:803-831-8966
Practice Address - Street 1:1100 VILLAGE HARBOR DR
Practice Address - Street 2:LAKE WYLIE FAMILY DENTISTRY PA
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710
Practice Address - Country:US
Practice Address - Phone:803-831-8856
Practice Address - Fax:803-831-8966
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3673122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist